A Rare Case of Rabies After Kidney Transplant

When a Life-Saving Transplant Becomes Fatal: Rabies Transmission Through a Donor Kidney

Organ transplantation is one of modern medicine’s most extraordinary successes. Every day, organs from deceased donors give patients a second chance at life, transforming fatal organ failure into survivable disease. Yet transplantation also represents one of the few remaining clinical frontiers where biology, urgency, uncertainty, and invisible risk collide.

In 2025, the transplant community was confronted with a deeply unsettling reminder of this reality: a kidney transplant recipient in the United States died from rabies transmitted through a donor organ. The event was exceptionally rare, medically complex, and ethically challenging — but its implications extend far beyond a single case.

This was not a failure of surgical technique or post-operative care. It was the tragic intersection of zoonotic disease, incomplete risk recognition, and the inherent limitations of donor screening in the face of rare but universally fatal infections.

The Case That Shocked Transplant Medicine
The recipient was an adult man who underwent a kidney transplant to treat end-stage renal disease. The donor had been declared brain-dead following a rapid neurological decline. At the time of organ procurement, there was no clinical diagnosis of rabies, nor any obvious signs that would immediately disqualify the donor under existing transplant screening protocols.

The transplant itself was technically successful. Initial post-operative recovery was unremarkable.

Approximately five weeks later, the recipient began to experience subtle neurological symptoms. These included tremors, confusion, muscle weakness, and difficulty coordinating movements. In a transplant patient, such symptoms are not uncommon and can be attributed to a wide differential diagnosis, including:

• Medication toxicity
  
  
• Metabolic disturbances
  
  
• Opportunistic infections
  
  
• Acute or chronic rejection
  
  
• Central nervous system complications related to immunosuppression
  

As days passed, the clinical picture worsened. The patient developed fever, difficulty swallowing, and profound neurological deterioration. A particularly alarming symptom soon emerged: hydrophobia, an intense aversion to water — a classic but rarely encountered hallmark of rabies.

Despite aggressive supportive care, the patient’s condition rapidly progressed to respiratory failure. He was intubated, transferred to intensive care, and died shortly thereafter. Postmortem testing confirmed rabies virus infection.

Tracing the Source: How Rabies Entered the Transplant Chain
Once rabies was identified, public health investigators initiated a detailed epidemiological investigation. The recipient had no history of animal bites, scratches, or wildlife exposure. There was no travel history or known exposure that could explain infection through conventional routes.

Attention turned to the donor.

Further review of donor history revealed that weeks before death, the donor had sustained a scratch from a wild skunkwhile handling a kitten outdoors. The scratch caused bleeding but was not initially considered significant. There was no reported bite, and no post-exposure rabies prophylaxis was administered.

At the time of donation, the donor had neurological symptoms, but rabies was not suspected clinically. Retrospective testing of preserved donor tissue later confirmed the presence of rabies virus genetic material within the transplanted kidney.

The conclusion was unavoidable: rabies had been transmitted directly through the donor organ.

Why Rabies Is Uniquely Dangerous in Transplant Medicine
Rabies occupies a singular place in infectious disease. Once clinical symptoms appear, survival is exceedingly rare. Mortality approaches 100%, even with intensive medical care.

What makes rabies particularly dangerous in transplantation is its ability to:

• Remain asymptomatic during incubation
  
  
• Evade routine donor screening
  
  
• Infect neural tissue without obvious early signs
  
  
• Become untreatable once symptoms develop
  

In immunocompetent individuals, rabies is almost always associated with an animal bite. In transplant recipients, however, the virus bypasses the skin entirely, entering the body via transplanted tissue and establishing infection under conditions of profound immunosuppression.

The virus travels along peripheral nerves toward the central nervous system, causing encephalitis, autonomic instability, and progressive neurological failure. Once hydrophobia, agitation, or paralysis develop, there is no effective curative treatment.

How Rare Is Transplant-Associated Rabies?
This case was only the fourth documented instance of rabies transmission through organ transplantation in the United States in nearly five decades. Fewer than a dozen recipients have ever been affected across all known cases.

This extreme rarity is precisely why rabies is not routinely tested for in organ donors. Unlike HIV or hepatitis viruses, rabies lacks a rapid, widely available screening test suitable for emergency donor evaluation. Testing is complex, time-consuming, and often requires specialized laboratories.

Given the urgency of organ procurement and the catastrophic consequences of delayed transplantation, transplant medicine has historically accepted a small degree of unavoidable infectious risk.

This case, however, demonstrates that low probability does not mean zero risk, especially when the consequences are absolute.

Diagnostic Delay: Why Rabies Is So Hard to Recognize
From a clinical perspective, the delay in diagnosing rabies was understandable. Early symptoms overlapped with common post-transplant complications. Fever, confusion, weakness, and tremors are frequently encountered in immunosuppressed patients.

Rabies is rarely considered because:

• Most clinicians will never encounter a case in their lifetime
  
  
• Animal exposure is often absent or undocumented
  
  
• Symptoms appear weeks to months after infection
  
  
• Early neurological signs are nonspecific
  

Only when classic features such as hydrophobia and autonomic instability appear does rabies enter the differential diagnosis — often too late for intervention.

This diagnostic challenge underscores the importance of contextual awareness, especially when a transplant recipient presents with unexplained, rapidly progressive neurological disease.

Public Health Response and Containment
Once rabies was confirmed, an extensive public health response was initiated. Hundreds of healthcare workers, family members, and close contacts were assessed for potential exposure. Risk stratification was performed based on contact with saliva or neural tissue.

Those deemed at risk received rabies post-exposure prophylaxis, including vaccination and immunoglobulin. Importantly, no secondary cases developed, demonstrating the effectiveness of rapid public health intervention once the diagnosis was made.

Other organ recipients from the same donor were also evaluated. Preventive measures were implemented swiftly, and no additional rabies infections were identified among them.

What This Case Reveals About Donor Screening
Current donor screening relies heavily on:

• Medical history
  
  
• Family interviews
  
  
• Risk questionnaires
  
  
• Standardized laboratory testing for common pathogens
  

Zoonotic infections like rabies present a unique challenge. Exposure histories may be incomplete or underestimated. Scratches or minor animal interactions may not be perceived as dangerous, particularly in regions where wildlife exposure is common.

This case highlights the need for:

• Greater emphasis on wildlife exposure history
  
  
• Heightened vigilance when donors present with unexplained neurological symptoms
  
  
• Early consultation with infectious disease and public health specialists when high-risk animal exposure is reported
  

However, it also reinforces that no screening system can eliminate all risk without fundamentally altering the speed and feasibility of organ transplantation.

Ethical Tension: Saving Lives Versus Preventing Rare Catastrophe
Transplant medicine operates under constant ethical tension. Delaying or rejecting organs due to uncertain risk can lead to deaths on waiting lists. Accepting organs carries the possibility of transmitting rare infections.

In this case, clinicians acted within accepted standards of care. There was no clear indication to test for rabies, no overt diagnosis, and no established protocol mandating exclusion.

The tragedy lies not in negligence, but in the limits of what medicine can reasonably anticipate.

Lessons for Clinicians
This case offers several critical lessons for doctors involved in transplantation and infectious disease care:

1. Rabies must be considered in transplant recipients with unexplained, rapidly progressive neurological symptoms
   
   
2. Animal exposure history matters, even when bites are not reported
   
   
3. Early public health involvement can prevent secondary transmission
   
   
4. Post-exposure prophylaxis can be life-saving if administered before symptom onset
   
   
5. Rare diseases still matter when the outcome is uniformly fatal
   

Most importantly, clinicians must remain humble in the face of biological unpredictability.

A Sobering Reminder
Organ transplantation remains overwhelmingly safe and life-saving. This case does not undermine that truth. Instead, it serves as a reminder that even the most advanced medical systems operate within a world shaped by pathogens, chance, and incomplete information.

Rabies did not enter the transplant system through error alone — it entered through nature’s complexity, human vulnerability, and the unavoidable gaps between what we know and what we can test for.

For the transplant community, the lesson is not fear — but vigilance.